Neurocrit Care (2012) 17:S102S111

DOI 10.1007/s12028-012-9759-0

REVIEW ARTICLE

Emergency Neurological Life Support: Traumatic Spine Injury

Deborah M. Stein Vincent Roddy
John Marx Wade S. Smith Scott D. Weingart

Published online: 11 September 2012

 Neurocritical Care Society 2012

Abstract Traumatic spine injuries (TSIs) carry significantly high risks of morbidity, mortality, and exorbitant
health care costs from associated medical needs following
injury. For these reasons, TSI was chosen as an ENLS
protocol. This article offers a comprehensive review on the
management of spinal column injuries using the best
available evidence. Though the review focuses primarily
on cervical spinal column injuries, thoracolumbar injuries
are briefly discussed as well. The initial emergency
department clinical evaluation of possible spinal fractures
and cord injuries, along with the definitive early management of confirmed injuries, are also covered.

D. M. Stein
University of Maryland School of Medicine, Baltimore, MD,
USA
D. M. Stein (&)
R Adams Cowley Shock Trauma Center, University of Maryland
Medical Center, Baltimore, MD, USA
e-mail: [email protected]
V. Roddy
Department of Emergency Medicine, Mount Sinai School
of Medicine, Elmhurst, NY, USA
J. Marx
Department of Emergency Medicine, University of North
Carolina, Charlotte Campus, Charlotte, NC, USA
W. S. Smith
Department of Neurology, University of California,
San Francisco, CA, USA
S. D. Weingart
Division of ED Critical Care, Mount Sinai School of Medicine,
New York, NY, USA
e-mail: [email protected]

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Keywords Myelopathy
Spine fracture

Spine decompression
Spine trauma
Paraplegia

Quadriplegia
Protocol

Introduction
Epidemiology
It is estimated that the annual incidence of spinal cord
injury (SCI) in the United States is *40 per million of
population, which equates to 12,000 new cases per year [1].
Mechanisms of spinal cord injuries are, in order of
frequency:

Motor vehicle collisions (42 %)

Falls (27 %)
Violence-related acts (15 %)
Sports injuries (8 %)
Other causes (9 %) [1].

In over 50 % of patients, injuries to the spine are isolated [2], while nearly 25 % have concomitant brain, chest,
and/or major extremity injuries [3]. Though classically
thought to be a disease of young males, recent epidemiological studies on patients with SCI depict a bimodal
distribution [4]. The first peak occurs in adolescents and
young adults, as expected. However, the second peak
occurs in the elderly population (age > 65 years) [4].
Life expectancy for a patient who sustains an SCI is
significantly lower than that for the general population [1].
However, average lifetime costs for a patient with SCI
range from almost $4,400,000 for a patient 25-year old
with high tetraplagia to $1,000,000 for a 50-year old with
an incomplete injury at any level [5].

Neurocrit Care (2012) 17:S102S111

Injuries to the spine tend to occur at areas of maximal

mobility. Cervical SCIs account for over 50 % of traumatic
SCIs and are associated with much higher short- and longterm morbidity than injuries affecting the cord at the thoracic
or lumbar level [57]. The most frequent injuries are
incomplete tetraplagia (31 %) followed by complete paraplegia (25 %), complete tetraplegia (20 %), and incomplete
paraplegia (19 %) [8].
Evaluation
When evaluating a blunt trauma victim, medical personnel
must assume that the patient has a spinal column injury
until proven otherwise. As a result, appropriate care must
be taken to provide spinal immobilization on scene. The
spinal column should be immobilized until an unstable
injury can be excluded. In the pre-hospital setting, patients
are typically fitted with a cervical collar to provide cervical
spinal column immobilization, and patients are subsequently transferred to the hospital on a backboard. If the
patient is intoxicated and uncooperative with medical
evaluation, chemical sedation may be indicated to assure
proper protection of the spinal column and, more importantly, the spinal cord.
Once in the emergency department (ED), the immediate
evaluation of a patient with a suspected cervical spinal
injury is no different from any other trauma patient. The
ABCsairway, breathing, and circulationtake utmost
priority. As a general rule, the diagnosis and treatment of
the majority of spine injuries can be deferred to address
other life-threatening injuries, such as hemorrhage or
intracranial mass lesions, as long as spine immobilization is
maintained.
Clinicians should perform their primary survey, assessing the patients ABCs and disability. Finally, the physician
should fully expose the patient looking for signs of injury.
During the disability portion of the primary survey,
clinicians should quickly perform a basic neurologic
assessment. In trauma patients during the primary survey,
this can be abbreviated to the patients Glasgow Coma
Scale (GCS), pupil size and reactivity, and ability to move
all four extremities. If the patient is intubated before these
three items can be assessed, it becomes more difficult to
assess prognosis and whether an injury occurred out-ofhospital or iatrogenically.
After the primary survey is conducted to assess for
potential life-threatening injuries, the secondary survey
should be completed. The secondary survey entails a
complete head-to-toe evaluation, including a more thorough history of present illness (if possible to obtain). In the
suspected spinal injury patient, the entire spinal column
and paravetebral musculature should be examined for
deformity and palpated in a search for areas of focal

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tenderness. Vertebral fractures or subluxations may be

represented as step-offs appreciated via palpation of the
spinal column or areas of focal tenderness along the midline of the back/neck. The presence of priapism in male
patients may also suggest SCI.
If any abnormalities are discovered during initial
screening, a detailed neurologic examination of motor and
sensory function at all spinal levels should be performed.
As during the primary survey, spinal precautions must be
maintained while evaluating the patient. When assessing
the cervical spine, it may be safer for the anterior portion of
the rigid cervical collar to remain on the patient, keeping
the head immobile while a clinician slips his or her hand
behind the neck to assess the spinal column. Clinicians
should perform serial neurologic evaluation if possible.
At the conclusion of the primary or secondary survey,
the patient should be removed as soon as possible from the
backboard, as evidence suggests that leaving a patient on
the backboard can lead to complications [9]. Pressure
ulcers or deep tissue injuries can develop when the pressure
applied to the skin is greater than the diastolic blood
pressure. Studies have shown that skin breakdown can
occur in as quickly as 1 h [9]. Tissue injury is more likely
in elderly patients, obese patients, those who are on harder
surfaces, and those who have suffered hypotension. Pressure ulcers and deep tissues injuries have been associated
with higher mortality rates, the need for costly medical
treatments, and longer hospital stays.
The ENLS-suggested algorithm for the initial management of traumatic spine injury (TSI) is shown in Fig. 1.
Suggested items to complete within the first hour of evaluating a patient with TSI are shown in Table 1.
Immobilization of Confirmed Injuries
Confirmed cervical spinal column fractures must be kept
immobile in a cervical collar and on log-roll precautions
until definitive management can be arranged. The initial
goal of treatment should be to prevent further injury caused
by spine motion with resultant worsening of neurologic
outcome.
In patients with confirmed cervical spinal column injuries, goals of treatment should be to immobilize the spine
while also minimizing the possibility of skin breakdown.
Studies have demonstrated that PhiladelphiaTM collars and
Miami JTM collars are more effective than standard emergency medical services (EMS) collars in reducing cervical
spinal column range of motion [10]. Miami JTM collars
have also been shown to apply the least amount of pressure
to the facial tissues of the patient compared to other cervical immobilizing collars [10].
Miami JTM collars are indicated in stable cervical spinal
column injuries from C2 to C5. A thoracic extension can be

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Neurocrit Care (2012) 17:S102S111

Fig. 1 ENLS TSI protocol

Table 1 TSI checklist for the first hour

h Immobilize C-spine until cleared
h Keep SBP > 90 mmHg
h C-spine precautions
h Head CT
h Treat herniation

added if immobilization is needed for a stable injury from

C6 to T2. It should be noted that no cervical collar will
prevent a determined or delirious patient from moving his
or her head, potentially worsening injury. Agitated patients
require pain control and sedation to maintain immobility.
Unstable high cervical lesions may require immobilization via the halo fixator, the most commonly applied
device for the treatment of high unstable spinal column
fractures, C1C3 [11]. Attached to the skull via metal pins,

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the halo fixator is often used for spine stability pending

operative reduction, as well as to provide spinal stabilization status post cervical spine surgery. Halo fixation can
reduce cervical spinal mobility by as much as 96 % [12].
Patients with spinal column injuries have historically
been moved only with log-roll precautions once in the
hospital, and this remains the standard of care in many
centers. However, the method has been called into question
by some practitioners given that significant movement of
the spinal column can still occur. The High Arm In
Endangered Spine (HAINES) method has been recommended by some researchers given that it may minimize
movement of the spine compared to the traditional log-roll
method [13, 14]. With the patient lying supine, the knees
are bent, and one arm is abducted to 180 with the other
arm across the patients chest. With a clinician providing
inline stabilization while on the side of the patient with the
arm across the chest, the patient can be gently rolled to his

Neurocrit Care (2012) 17:S102S111

or her side, and a transfer device can be placed underneath

the patient.
Who to Image
To avoid unnecessary radiation exposure, patients with low
or moderate pre-test probability of cervical spinal injury
should undergo evaluation with a clinical decision rule
before imaging. Both the NEXUS criteria [15] and the
Canadian C-Spine Rules (CCR) [16, 17] are widely used
within clinical practice in the evaluation of patients with
suspected cervical spine injuries.
NEXUS
In the NEXUS study, a clinical clearance protocol consisting of five criteria was validated with a 100 %
sensitivity for the exclusion of cervical spinal injury [15].
The first criterion requires the physician to search for signs
of intoxication in the patient. In the original study, patients
were not allowed to even smell of alcohol. The second
criterion requires the physician to assess for the presence of
focal neurologic deficits. The third criterion is the assessment for the presence of painful distracting injuries. A
distracting injury has no specific definition in the NEXUS
study, but examples in the study that prevented clinical
clearance were:

Long bone fractures

Large lacerations
De-gloving or crush injuries
Large burn(s)
Visceral injuries needing surgical consultation
Any injuries producing acute functional impairment [18].

With the fourth criterion, the physician should assess

whether the patient has a normal level of alertness. Specifically, there should be no delay or inappropriate response
to external stimuli by the patient. Finally, to assess the fifth
criterionthe presence of posterior midline tenderness to
palpationthe physician should unhook the velcro strap of
the cervical collar and, with the anterior collar still in place,
push on each vertebrae, monitoring the patient for a
response to pain. Using the NEXUS criteria, if no painful
response is elicited, and the patient has met all prior criteria, the C-collar can be removed and C-spine imaging
will not be needed.

Canadian C-Spine Rules

The CCR does not preclude clinical clearance solely due to
posterior neck tenderness [16]. It includes both high- and

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low-risk criteria that allow clearance in patients 18- to

65-year old (see http://www.mdcalc.com/canadian-cspine-rule/). While more difficult to remember, the
greater specificity of the CCR may allow additional
patients to be cleared when compared to the NEXUS criteria [16]. The presence of posterior neck tenderness may
be one of the deciding points for which rule to choose. If
the patient has posterior tenderness, NEXUS will not be
usable, but the patient may still avoid imaging with the
CCR.
Neck Rotation
In the CCR, the final stage of clearance is to have the
patient rotate his or her head 45 to the left and right. The
inability of the patient to perform this maneuver is an
indication for further imaging. Though this stage was not a
reported part of the NEXUS criteria, it is still recommended as an appropriate final step in clearance. During
this portion of the evaluation, the clinician should
remember that minimal pain during active range of motion
is allowed to be experienced by the patient. However, if the
action proves too painful to complete, ligamentous injury is
a possibility; therefore, the C-collar should be left in place
and imaging pursued.
In the past, a 3-view cervical spine radiograph series
was the standard initial evaluation for cervical spine injury.
Recently, the Eastern Association for the Surgery of
Trauma (EAST) and the American College of Radiology
have recommended that computed tomography (CT) with
multi-planar reconstruction should be the initial imaging
modality [19, 20]. If plain radiographs are still used in
suspected cervical spine injuries, they are only appropriate
in patients who are risk-stratified to low pre-test
probability.
If initial imaging is negative (radiograph or CT scan),
the clinician should attempt to clear the collar. If the
patient still has persistent midline tenderness at the time of
collar clearance, the collar should be replaced. If there is no
significant midline tenderness, the patient should be asked
to range left and right 45 as mentioned above. If the
patient is unable to range, the collar should be replaced. At
this point, institutional protocol should dictate further
imaging, consultation, or discharge in a collar combined
with urgent follow-up with a spine or trauma service.
Clinical judgment must be used for the clearance of
possible thoracolumbar (TL) spinal column injuries, as
there are currently no validated guidelines. Focal tenderness over the TL spine, neurologic deficit, and high energy
mechanism are risk factors that have been identified to be
associated with TL spinal column injuries [21].
In addition, in patients with one vertebral column fracture, the presence of a second non-adjoining fracture has

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been estimated to have an incidence of up to 15 % [22]. As

a result, when one fracture has been identified, it is recommended that the entire spinal column undergoes
imaging to assess for concomitant fracture.

Neurocrit Care (2012) 17:S102S111

Table 2 Indications for intubation of the patient with traumatic cervical spine injury
Absolute indications
Complete SCI above C5 level
Respiratory distress
Hypoxemia despite attempts at oxygenation

Confirmed TSI

Severe respiratory acidosis

Relative indications

Initial Management
Once a fracture has been diagnosed, the patient should be
maintained with spinal precautions during all treatments.
As opposed to patients with spinal column injuries without
deficit or patients with TL injuries, patients with cervical
SCIs often have life-threatening issues that are a direct
consequence of their spine injury. These issues require
emergent attention and take priority in the acute management of these patients.
Airway
Patients with cervical SCI can be at high risk of loss of
airway due to a number of factors. Airway and neck edema
or hematoma from direct neck trauma and local bleeding
can contribute to loss of the airway. In patients with high
cervical SCI, loss of diaphragmatic innervation via injury to
C3C5 levels, as well as loss of chest and abdominal wall
strength, contributes significantly to a patients inability to
maintain adequate oxygenation and ventilation. Patients
with high (above C3) complete SCI will almost invariably
suffer a respiratory arrest in the field and, if not intubated by
pre-hospital providers, typically present in cardiac arrest.
As a general rule, all patients with a complete cervical
SCI above C5 should be intubated as soon as possible [23,
24]. See Table 2 for indications for intubation in patients
with spinal cord injury. Patients with incomplete or lower
injuries will have a high degree of variability in their
ability to maintain adequate oxygenation and ventilation.
General parameters for urgent intubation include:

Obvious respiratory distress/Dyspnea

Complaint of inability to catch my breath
Inability to hold breath for 12 s [25]
Vital capacity (VC) <10 mL/kg or decreasing VC
Appearance of belly breathing or quad breathing
(abdomen goes out sharply with inspiration).

When in doubt, it is better to electively intubate a patient

with a cervical SCI than to wait until it must be performed
emergently. Patients will typically develop worsening of
their primary injury shortly after admission due to cord
edema and progressive loss of muscle strength; therefore,
vigilance in monitoring these patients and watching for
worsening of respiratory status is essential [24]. Table 2

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Complaint of shortness of breath

Development of quad breathing
VC of <10 mL/kg or decreasing VC
Consideration should be given
Need to travel remote from ED (MRI, transfer to another facility)

provides some absolute and relative indications for urgent

intubation in patients with an acute cervical SCI.
Generally, patients with cervical SCI, who require nonurgent intubation should be intubated by an experienced
provider using an awake fiberoptic approach. This will
minimize movement of the cervical spine and the risk of
exacerbation of SCI in the setting of ligamentous or fracture
instability. It will also allow for a neurological examination
following intubation to document any changes. Patients
who require urgent or emergent intubation should be intubated using rapid sequence intubation (RSI) [26].
There are a few special issues related to intubation in the
patient with a cervical SCI that deserve mention. Aspiration precautions should always be taken, as they should for
any emergent intubation. The cervical collar must be
removed with inline stabilization carefully maintained, and
extreme care must be taken not to hyper-extend the neck to
minimize the risk of worsening the injury.
No particular RSI medication regimen is recommended,
but in the selection of drugs, it should be considered that
many of these patients may already be vasodilated from
loss of sympathetic tone. Therefore, medications that further diminish the catecholamine surge may result in
exacerbation of hypotension and bradycardia [27, 28].
Tracheal or laryngeal manipulation can also stimulate a
bradycardic response in these patients, as can any degree of
hypoxia [29, 30].
Atropine should always be immediately available when
manipulating the airway of a patient with an acute cervical
SCI. Though traditionally avoided in patients with SCI due
to the risk of hyperkalemia from depolarization [31],
succinylcholine is safe to use if within the first 48 h after
injury, prior to up-regulation of acetylcholine receptors [23].
Breathing
Patients with cervical SCI are at high risk of inadequate
oxygenation and ventilation due to a combination of factors

Neurocrit Care (2012) 17:S102S111

[24]. As mentioned above, high cervical SCIs result in loss

of diaphragmatic function and can cause apnea. The chest
wall and abdominal musculature that are so vital for
effective ventilation are often severely compromised, even
in patients with incomplete injuries. This results in hypoventilation and a significant loss of ability to generate an
effective cough and clear secretions. Aspiration, retention
of secretions, and the almost invariable development of
atelectasis contribute to respiratory decompensation.
In addition, concomitant injuries such as pulmonary
contusions and pneumothoraces are frequently found in the
polytrauma patient. Up to 65 % of patients with cervical
SCI will have evidence of respiratory dysfunction on
admission to the Intensive Care Unit (ICU) [32]. Supplemental oxygen should be supplied to all patients with
cervical SCI to maintain a oxygen saturation > 95 %, as
hypoxemia is extremely detrimental to patients with neurological injury. Moreover, hypoxemia can cause severe
bradycardia in patients with high cervical SCIs due to vagal
stimulation [29, 30]. Non-invasive methods of ventilation
should be used with caution in this patient population, as
the inability to cough and clear secretions may lead to an
increased risk of aspiration.

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and ischemia of the spinal cord, resulting in ascension of

their injury [35, 36]. Of note, the term spinal shock has
nothing to do with hemodynamics, but rather refers to the
loss of spinal reflexes below the level of injury [37].
First line treatment of neurogenic shock is always fluid
resuscitation to maintain euvolemia [23]. The loss of
sympathetic tone leads to vasodilation and the need for an
increase in the circulating blood volume (often referred to
as filling the tank). Non-invasive or invasive monitors of
volume responsiveness may be helpful in establishing fluid
resuscitation goals.
Once euvolemia is established, second line therapy is
pressors and/or inotropes [38]. There is currently no
established recommended single agent, though potential
agents include:

Circulation
Patients with SCI above the T4 level are at high risk of the
development of neurogenic shock [23]. The patient suffers
a sympathectomy, resulting in unopposed vagal tone. This
leads to a distributive shock with hypotension and bradycardia, though variable heart rates have also been described
[33].
Patients with neurogenic shock are generally hypotensive with warm, dry skin, as opposed to patients with
hypovolemic shock from hemorrhage. This is due to the
loss of sympathetic tone, resulting in an inability to redirect
blood flow from the periphery to the core circulation.
However, in the patient with multiple injuries, other causes
of hypotension, such as hemorrhagic shock, can be present.
These causes must be identified and immediately
addressed.
Bradycardia is a characteristic finding of neurogenic
shock and may help to differentiate from other forms of
shock. Care should be taken not to assume that a patient
has neurogenic shock because of a lack of tachycardia, as
young, healthy patients, elderly patients, and patients on
pre-injury beta-blockers will often not manifest tachycardia
in the setting of hemorrhage.
As a general rule, the higher and more complete the
injury, the more severe and refractory the neurogenic shock
[34]. These signs can be expected to last from 1 to 3 weeks.
Patients may develop manifestations of neurogenic shock
hours to days following injury due to progressive edema

Norepinephrine It has both alpha and some beta

activity, thereby improving both blood pressure and
bradycardia, and is most likely the preferred agent
Phenylephrine A pure alpha agonist that is very
commonly used, easily titratable, and safe for use
through a peripheral line. It lacks beta activity so does
not treat bradycardia and may actually worsen it
through reflexive mechanisms [23]. Best used in
patients with high thoracic lesions in whom bradycardia
is less of a concern
Dopamine Also frequently used, but high doses
(>10 mcg/kg/min) are needed to obtain the alpha
vasoconstrictor effect. If dopamine is used, it may lead
to diuresis from dopaminergic stimulation, exacerbating hypovolemia.
Epinephrine An alpha and beta-agonist that causes
vasoconstriction and increased cardiac output. The high
doses that may be required can lead to inadvertent
mucosal ischemia. In most centers, it is rarely used or
needed
Dobutamine It can be useful, as it is a pure beta-agonist
that treats bradycardia, and may be helpful for treatment of hypotension if the loss of sympathetic tone
causes cardiac dysfunction. Caution should be taken in
patients who are not adequately volume loaded, as it
may cause hypotension

In addition to treatment of neurogenic shock, some

institutions utilize a protocol based on the American
Association of Neurological Surgeons and the Congress of
Neurological Surgeons Guidelines for the Management of
Acute Cervical Spine and Spinal Cord Injuries. These
entities recommend maintenance of mean arterial blood
pressure (MAP) at 8590 mmHg for the first 7 days following acute SCI to improve spinal cord perfusion [39].
This is based on uncontrolled studies that demonstrated
benefit in patients who were maintained with a MAP of 85
for 7 days following injury [40, 41].

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Neurocrit Care (2012) 17:S102S111

Disability-Neurological Examination

3.

Motor and Sensory Exams

4.
The neurological examination in any patient with suspected
SCI should focus on motor, sensory, and rectal tone and
sensation findings. If the patient has abnormality in any of
these areas, the lesion should be localized to the highest spinal
level where dysfunction is noted. As a general guide, some of
the commonly referred to motor and sensory levels are:
Motor

C4deltoid
C5biceps
C6wrist extensors
C7triceps
T1finger abduction
L2hip flexors
L3knee flexion
L4ankle dorsiflexion
S1plantar flexion

Sensory

5.

Complete injuries, defined by the absence of sensory or

motor function below a spinal level, have a worse prognosis for functional recovery. One caveat is that in the
setting of significant spinal shock, the absence of sensation
or function may be a manifestation of the spinal shock
itself as opposed to the primary injury. Once the spinal
shock resolves, incomplete injuries may become unmasked
[42]. Incomplete injuries have a much better prognosis for
functional recovery.
Syndromes
There are also a number of discrete neurological syndromes that have been described. If present, these
syndromes help indicate the extent and nature of the injury:

C4deltoid
T4nipple
T10umbilicus

The levels above refer to the respective myotomes and

dermatomes for these regions of dysfunction. A rectal
exam is of utmost importance in the patient with a suspected SCI, as decreased rectal tone may be the only sign
of an SCI and helps differentiate complete from incomplete
lesions, which is of vital importance in prognostication for
recovery of function.

ASIA Scale
The full examination recommended by the American Spinal
Injury Association (ASIA) (found at http://www.asia-spinal
injury.org/publications/Motor_Exam_Guide.pdf and http://
www.asia-spinalinjury.org/publications/Key_Sensory_Points.
pdf) includes a detailed motor and sensory examination. It is
the preferred evaluation tool as recommended by the
American Association of Neurological Surgeons and the
Congress of Neurological Surgeons [25].
ASIA also defines a five-element scale, the ASIA
Impairment Scale (AIS), that is prognostic of neurological
recovery:
1.
2.

Complete No motor or sensory function in the lowest

sacral segment.
Incomplete Sensory but not motor function is preserved in the lowest sacral segment.

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Incomplete Less than 1/2 of the key muscles below the

neurological spinal level have grade 3 or better
strength.
Incomplete At least 1/2 of the key muscles below the
neurological level have grade 3 or better strength.
Normal Sensory and motor functions are normal.

Anterior Cord Syndrome Described as a loss of pain/

temperature and motor with preservation of light touch.
It is caused by injury to the anterior spinal cord,
commonly from contusion or occlusion of the anterior
spinal artery. Anterior Cord Syndrome is associated
with axial compression causing burst fractures of the
spinal column with fragment retropulsion.
Central Cord Syndrome The loss of cervical motor
function with relative sparing of lower extremity
strength. This is most often due to hyperextension
injury, commonly seen in elderly patients with cervical
stenosis [43, 44]. It is usually not associated with a
fracture, but rather with a buckling of the ligamentum
flavum that contuses the cord, causing bleeding within
the center of the cord. The amount of damage to the
laterally located corticospinal tracts is variable and
determines the amount of lower extremity weakness.
Brown-Sequard Syndrome It is described as a hemiplegia with loss of ipsilateral light touch and contralateral
pain/temperature sensation. This is due to traumatic
hemisection of the cord. It is most frequently seen with
penetrating cord injury, often from missiles or knife
wounds, or a lateral mass fracture of the spine.

Treatment
The mainstay of treatment for SCIs is decompression of the
spinal cord to minimize additional injury from cord compression, surgical stabilization of unstable ligamentous and
bony injury, and minimizing the effect of secondary

Neurocrit Care (2012) 17:S102S111

complications, such as venous thromboembolic disease,

pressure ulcer prevention, respiratory failure, and infections.
Early consideration should be given to placement of
indwelling urinary catheters, both to monitor volume status
and prevent urinary retention [23, 42]. In addition, stress
ulcer prophylaxis should be initiated early following injury,
due to an increased risk of gastrointestinal bleeding in
patients with cervical SCI [4547].
There are few therapeutic options for the injured spine
itself. Though there has been extensive research in the
field, no neuroprotective therapy has been definitively
proven effective in improving outcome following traumatic
SCI [23].

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suggesting harmful side effects is more consistent than any

suggestion of clinical benefit [39]. An additional 15
medical societies have also stated that steroids should not
be considered the standard of care after SCI. We recommend that steroids should not be given except in the setting
of experimental or research protocols.
If steroids are to be used, the recommended regimen is
methyprednisolone 30 mg/kg as a bolus, then 5.4 mg/kg/h
for 23 or 47 h. Care should be taken, as this regimen often
causes severe nausea and can lead to emesis and aspiration.
The steroid protocol should only be used if initiated within
8 h of injury and should never be used in the setting of
penetrating CSI, due to the risk of infection and lack of
demonstration of efficacy [23].

Steroids
Communication
The use of steroids following acute traumatic cervical
spinal injury is highly controversial and is both institution
and practitioner specific. The use of steroids following SCI
is based on experimental work in animal models that
suggested methylprednisolone has neuroprotective effects
through an anti-inflammatory mechanism [48, 49]. This led
to the National Acute Spinal Cord Injury Studies (NASCIS) trials. NASCIS II concluded that there was efficacy
of high dose methylprednisolone in patients who had
received the drug within 8 h after injury [50, 51].
As a result, this regimen quickly became the standard of
care. However, there has been extensive debate and discussion about the validity of the results, as well as an
inability to confirm the results in additional trials [5258].
Moreover, extensive concerns have been raised about
increased complications, such as pneumonia and gastrointestinal bleeding in patients treated with steroids following
acute cervical SCI [5961].
Based on these circumstances, the most recent version
of the American Association of Neurological Surgeons and
the Congress of Neurological Surgeons Guidelines for the
Management of Acute Cervical Spine and Spinal Cord
Injuries states: There is insufficient evidence to support
treatment standards. Methylprednisolone for either 24 or
48 h is recommended as an option in the treatment of
patients with acute spinal cord injuries that should be
undertaken only with the knowledge that the evidence
Table 3 TSI communication regarding assessment and referral
Age
Mechanism of injury
GCS
Coagulation studies
Other injuries
State of C-spine
CT scan results

When communicating to an accepting or referring physician about this patient, consider including the key elements
listed in Table 3.
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Accessed 2 Feb 2012.
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spinal cord. 6th ed. New York: McGraw-Hill; 2011.
3. Saboe LA, Reid DC, Davis LA, Warren SA, Grace MG. Spine
trauma and associated injuries. J Trauma. 1991;31:438.
4. Jabbour P, Fehlings M, Vaccaro AR, Harrop JS. Traumatic spine
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